EXAM 1 211 – Test Bank Questions
Chapter 12: Assessment and Care of Patients with Acid-Base Imbalances
MULTIPLE CHOICE
1. A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The
clients arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3 18
mEq/L. Which manifestation should the nurse identify as an example of the clients compensation
mechanism?
a. Increased rate and depth of respirations
b. Increased urinary output
c. Increased thirst and hunger
d. Increased release of acids from the kidneys
2. A nurse assesses a client who is experiencing an acid-base imbalance. The clients arterial blood
gas values are pH 7.34, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3 19 mEq/L. Which
assessment should the nurse perform first?
a. Cardiac rate and rhythm
b. Skin and mucous membranes
c. Musculoskeletal strength
d. Level of orientation
3. A nurse assesses a client who is prescribed furosemide (Lasix) for hypertension. For which acidbase imbalance should the nurse assess to prevent complications of this therapy?
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis
4. A nurse is caring for a client who is experiencing moderate metabolic alkalosis. Which action
should the nurse take?
a. Monitor daily hemoglobin and hematocrit values.
b. Administer furosemide (Lasix) intravenously.
c. Encourage the client to take deep breaths.
d. Teach the client fall prevention measures.
5. A nurse is assessing a client who has acute pancreatitis and is at risk for an acid-base imbalance.
For which manifestation of this acid-base imbalance should the nurse assess?
a. Agitation
b. Kussmaul respirations
c. Seizures
d. Positive Chvosteks sign
6. A nurse assesses a client who is admitted with an acid-base imbalance. The clients arterial blood
gas values are pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L. What action
should the nurse take next?
a. Assess clients rate, rhythm, and depth of respiration.
b. Measure the clients pulse and blood pressure.
c. Document the findings and continue to monitor.
d. Notify the physician as soon as possible.
EXAM 1 211 – Test Bank Questions
7. A nurse is caring for a client who has the following arterial blood values: pH 7.12, PaO2 56 mm
Hg, PaCO2 65 mm Hg, and HCO3 22 mEq/L. Which clinical situation should the nurse correlate
with these values?
a. Diabetic ketoacidosis in a person with emphysema
b. Bronchial obstruction related to aspiration of a hot dog
c. Anxiety-induced hyperventilation in an adolescent
d. Diarrhea for 36 hours in an older, frail woman
8. A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The
clients arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3 22
mEq/L. Which action should the nurse take first?
a. Apply oxygen by mask or nasal cannula.
b. Apply a paper bag over the clients nose and mouth.
c. Administer 50 mL of sodium bicarbonate intravenously.
d. Administer 50 mL of 20% glucose and 20 units of regular insulin.
9. After teaching a client who was malnourished and is being discharged, a nurse assesses the
clients understanding. Which statement indicates the client correctly understood teaching to
decrease risk for the development of metabolic acidosis?
a. I will drink at least three glasses of milk each day.
b. I will eat three well-balanced meals and a snack daily.
c. I will not take pain medication and antihistamines together.
d. I will avoid salting my food when cooking or during meals.
10. A nurse evaluates the following arterial blood gas values in a client: pH 7.48, PaO2 98 mm Hg,
PaCO2 28mm Hg, and HCO3 22 mEq/L. Which client condition should the nurse correlate with
these results?
a. Diarrhea and vomiting for 36 hours
b. Anxiety-induced hyperventilation
c. Chronic obstructive pulmonary disease (COPD)
d. Diabetic ketoacidosis and emphysema
11. After providing discharge teaching, a nurse assesses the clients understanding regarding
increased risk for metabolic alkalosis. Which statement indicates the client needs additional
teaching?
a. I dont drink milk because it gives me gas and diarrhea.
b. I have been taking digoxin every day for the last 15 years.
c. I take sodium bicarbonate after every meal to prevent heartburn.
d. In hot weather, I sweat so much that I drink six glasses of water each day.
12. A nurse is caring for a client who is experiencing excessive diarrhea. The clients arterial blood
gas values are pH 7.28, PaO2 98 mm Hg, PaCO2 45 mm Hg, and HCO3 16 mEq/L. Which provider
order should the nurse expect to receive?
a. Furosemide (Lasix) 40 mg intravenous push
b. Sodium bicarbonate 100 mEq diluted in 1 L of D5W
c. Mechanical ventilation
d. Indwelling urinary catheter
EXAM 1 211 – Test Bank Questions
13. A nurse evaluates a clients arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg, PaCO2
55 mmHg, and HCO3 22 mEq/L. Which intervention should the nurse implement first?
a. Assess the airway.
b. Administer prescribed bronchodilators.
c. Provide oxygen.
d. Administer prescribed mucolytics.
14. A nurse is planning care for a client who is hyperventilating. The clients arterial blood gas
values are pH 7.30, PaO2 94 mm Hg, PaCO2 31 mm Hg, and HCO3 26 mEq/L. Which question
should the nurse ask when developing this clients plan of care?
a. Do you take any over-the-counter medications?
b. You appear anxious. What is causing your distress?
c. Do you have a history of anxiety attacks?
d. You are breathing fast. Is this causing you to feel light-headed?
15. A nurse is caring for a client who has chronic emphysema and is receiving oxygen therapy at 6
L/min via nasal cannula. The following clinical data are available:
Arterial Blood Gases Vital Signs
pH = 7.28 Pulse rate = 96 beats/min
PaO2 = 85 mm Hg Blood pressure = 135/45
PaCO2 = 55 mm Hg Respiratory rate = 6 breaths/min
HCO3 = 26 mEq/L O2 saturation = 88%
Which action should the nurse take first?
a. Notify the Rapid Response Team and provide ventilation support.
b. Change the nasal cannula to a mask and reassess in 10 minutes.
c. Place the client in Fowlers position if he or she is able to tolerate it.
d. Decrease the flow rate of oxygen to 2 to 4 L/min, and reassess.
MULTIPLE RESPONSE
1. A nurse is planning interventions that regulate acid-base balance to ensure the pH of a clients
blood remains within the normal range. Which abnormal physiologic functions may occur if the
client experiences an acid- base imbalance? (Select all that apply.)
a. Reduction in the function of hormones
b. Fluid and electrolyte imbalances
c. Increase in the function of selected enzymes
d. Excitable cardiac muscle membranes
e. Increase in the effectiveness of many drugs
2. A nurse assesses a client who is experiencing an acid-base imbalance. The clients arterial blood
gas values are pH 7.32, PaO2 94 mm Hg, PaCO2 34 mm Hg, and HCO3 18 mEq/L. For which
clinical manifestations should the nurse assess? (Select all that apply.)
a. Reduced deep tendon reflexes
b. Drowsiness
c. Increased respiratory rate
d. Decreased urinary output
e. Positive Trousseaus sign
EXAM 1 211 – Test Bank Questions
3. A nurse is assessing clients who are at risk for acid-base imbalance. Which clients are correctly
paired with the acid-base imbalance? (Select all that apply.)
a. Metabolic alkalosis Young adult who is prescribed intravenous morphine sulfate for pain
b. Metabolic acidosis Older adult who is following a carbohydrate-free diet
c. Respiratory alkalosis Client on mechanical ventilation at a rate of 28 breaths/min
d. Respiratory acidosis Postoperative client who received 6 units of packed red blood cells
e. Metabolic alkalosis Older client prescribed antacids for gastroesophageal reflux disease
4. A nurse assesses a client who is receiving total parenteral nutrition. For which adverse effects
related to an acid-base imbalance should the nurse assess? (Select all that apply.)
a. Positive Chvosteks sign
b. Elevated blood pressure
c. Bradycardia
d. Increased muscle strength
e. Anxiety and irritability
5. A nurse is planning care for a client who is anxious and irritable. The clients arterial blood gas
values are pH 7.30, PaO2 96 mm Hg, PaCO2 43 mm Hg, and HCO3 19 mEq/L. Which questions
should the nurse ask the client and spouse when developing the plan of care? (Select all that apply.)
a. Are you taking any antacid medications?
b. Is your spouses current behavior typical?
c. Do you drink any alcoholic beverages?
d. Have you been experiencing any vomiting?
e. Are you experiencing any shortness of breath?
EXAM 1 211 – Test Bank Questions
Chapter 17: Inflammation and Immunity
MULTIPLE CHOICE
1. The student nurse learns that the most important function of inflammation and immunity is
which purpose?
a. Destroying bacteria before damage occurs
b. Preventing any entry of foreign material
c. Providing protection against invading organisms
d. Regulating the process of self-tolerance
2. A nurse is assessing an older client for the presence of infection. The clients temperature is 97.6 F
(36.4 C). What response by the nurse is best?
a. Assess the client for more specific signs.
b. Conclude that an infection is not present.
c. Document findings and continue to monitor.
d. Request that the provider order blood cultures.
3. A client is taking prednisone to prevent transplant rejection. What instruction by the nurse is
most important?
a. Avoid large crowds and people who are ill.
b. Check over-the-counter meds for acetaminophen.
c. Take this medicine exactly as prescribed.
d. You have a higher risk of developing cancer.
4. A clinic nurse is working with an older client. What assessment is most important for preventing
infections in this client?
a. Assessing vaccination records for booster shot needs
b. Encouraging the client to eat a nutritious diet
c. Instructing the client to wash minor wounds carefully
d. Teaching hand hygiene to prevent the spread of microbes
5. A client has a leg wound that is in the second stage of the inflammatory response. For what
manifestation does the nurse assess?
a. Noticeable rubor
b. Purulent drainage
c. Swelling and pain
d. Warmth at the site
6. A nursing student learning about antibody-mediated immunity learns that the cell with the most
direct role in this process begins development in which tissue or organ?
a. Bone marrow
b. Spleen
c. Thymus
d. Tonsils
7. The nurse understands that which type of immunity is the longest acting?
a. Artificial active
b. Inflammatory
c. Natural active
d. Natural passive
EXAM 1 211 – Test Bank Questions
8. The nurse working with clients who have autoimmune diseases understands that what
component of cell- mediated immunity is the problem?
a. CD4+ cells
b. Cytotoxic T cells
c. Natural killer cells
d. Suppressor T cells
9. A client has been on dialysis for many years and now is receiving a kidney transplant. The client
experiences hyperacute rejection. What treatment does the nurse prepare to facilitate?
a. Dialysis
b. High-dose steroid administration
c. Monoclonal antibody therapy
d. Plasmapheresis
10. A nurse is assessing a client for acute rejection of a kidney transplant. What assessment finding
requires the most rapid communication with the provider?
a. Blood urea nitrogen (BUN) of 18 mg/dL
b. Cloudy, foul-smelling urine
c. Creatinine of 3.9 mg/dL
d. Urine output of 340 mL/8 hr
11. The nurse working in an organ transplantation program knows that which individual is
typically the best donor of an organ?
a. Child
b. Identical twin
c. Parent
d. Same-sex sibling
12. An older adult has a mild temperature, night sweats, and productive cough. The clients
tuberculin test comes back negative. What action by the nurse is best?
a. Recommend a pneumonia vaccination.
b. Teach the client about viral infections.
c. Tell the client to rest and drink plenty of fluids.
d. Treat the client as if he or she has tuberculosis (TB).
13. A client receiving muromonab-CD3 (Orthoclone OKT3) asks the nurse how the drug works.
What response by the nurse is best?
a. It increases the elimination of T lymphocytes from circulation.
b. It inhibits cytokine production in most lymphocytes.
c. It prevents DNA synthesis, stopping cell division in activated lymphocytes.
d. It prevents the activation of the lymphocytes responsible for rejection.
MULTIPLE RESPONSE
1. For a person to be immunocompetent, which processes need to be functional and interact
appropriately with each other? (Select all that apply.)
a. Antibody-mediated immunity
b. Cell-mediated immunity
c. Inflammation
d. Red blood cells
e. White blood cells
EXAM 1 211 – Test Bank Questions
2. A student nurse is learning about the types of different cells involved in the inflammatory
response. Which principles does the student learn? (Select all that apply.)
a. Basophils are only involved in the general inflammatory process.
b. Eosinophils increase during allergic reactions and parasitic invasion.
c. Macrophages can participate in many episodes of phagocytosis.
d. Monocytes turn into macrophages after they enter body tissues.
e. Neutrophils can only take part in one episode of phagocytosis.
3. The nurse assesses clients for the cardinal signs of inflammation. Which signs/symptoms does this
include? (Select all that apply.)
a. Edema
b. Pulselessness
c. Pallor
d. Redness
e. Warmth
4. Which are steps in the process of making an antigen-specific antibody? (Select all that apply.)
a. Antibody-antigen binding
b. Invasion
c. Opsonization
d. Recognition
e. Sensitization
5. The student nurse is learning about the functions of different antibodies. Which principles does
the student learn? (Select all that apply.)
a. IgA is found in high concentrations in secretions from mucous membranes.
b. IgD is present in the highest concentrations in mucous membranes.
c. IgE is associated with antibody-mediated hypersensitivity reactions.
d. IgG comprises the majority of the circulating antibody population.
e. IgM is the first antibody formed by a newly sensitized B cell.
EXAM 1 211 – Test Bank Questions
Chapter 18: Care of Patients with Arthritis and Other Connective Tissue Diseases
MULTIPLE CHOICE
1. A nurse is working with a community group promoting healthy aging. What recommendation is
best to help prevent osteoarthritis (OA)?
a. Avoid contact sports.
b. Get plenty of calcium.
c. Lose weight if needed.
d. Engage in weight-bearing exercise.
2. A nurse in the family clinic is teaching a client newly diagnosed with osteoarthritis (OA) about
drugs used to treat the disease. For which medication does the nurse plan primary teaching?
a. Acetaminophen (Tylenol)
b. Cyclobenzaprine hydrochloride (Flexeril)
c. Hyaluronate (Hyalgan)
d. Ibuprofen (Motrin)
3. The clinic nurse assesses a client with diabetes during a checkup. The client also has
osteoarthritis (OA). The nurse notes the clients blood glucose readings have been elevated. What
question by the nurse is most appropriate?
a. Are you compliant with following the diabetic diet?
b. Have you been taking glucosamine supplements?
c. How much exercise do you really get each week?
d. Youre still taking your diabetic medication, right?
4. The nurse working in the orthopedic clinic knows that a client with which factor has an absolute
contraindication for having a total joint replacement?
a. Needs multiple dental fillings
b. Over age 85
c. Severe osteoporosis
d. Urinary tract infection
5. An older client has returned to the surgical unit after a total hip replacement. The client is
confused and restless. What intervention by the nurse is most important to prevent injury?
a. Administer mild sedation.
b. Keep all four siderails up.
c. Restrain the clients hands.
d. Use an abduction pillow.
6. What action by the perioperative nursing staff is most important to prevent surgical wound
infection in a client having a total joint replacement?
a. Administer preoperative antibiotic as ordered.
b. Assess the clients white blood cell count.
c. Instruct the client to shower the night before.
d. Monitor the clients temperature postoperatively.
7. The nurse on the postoperative inpatient unit assesses a client after a total hip replacement. The
clients surgical leg is visibly shorter than the other one and the client reports extreme pain. While a
co-worker calls the surgeon, what action by the nurse is best?
a. Assess neurovascular status in both legs.
b. Elevate the affected leg and apply ice.
c. Prepare to administer pain medication.
d. Try to place the affected leg in abduction.
EXAM 1 211 – Test Bank Questions
8. A client has a continuous passive motion (CPM) device after a total knee replacement. What
action does the nurse delegate to the unlicensed assistive personnel (UAP) after the affected leg is
placed in the machine while the client is in bed?
a. Assess the distal circulation in 30 minutes.
b. Change the settings based on range of motion.
c. Raise the lower siderail on the affected side.
d. Remind the client to do quad-setting exercises.
9. After a total knee replacement, a client is on the postoperative nursing unit with a continuous
femoral nerve blockade. On assessment, the nurse notes the clients pulses are 2+/4+ bilaterally; the
skin is pale pink, warm, and dry; and the client is unable to dorsiflex or plantarflex the affected
foot. What action does the nurse perform next?
a. Document the findings and monitor as prescribed.
b. Increase the frequency of monitoring the client.
c. Notify the surgeon or anesthesia provider immediately.
d. Palpate the clients bladder or perform a bladder scan.
10. A nurse is discharging a client to a short-term rehabilitation center after a joint replacement.
Which action by the nurse is most important?
a. Administering pain medication before transport
b. Answering any last-minute questions by the client
c. Ensuring the family has directions to the facility
d. Providing a verbal hand-off report to the facility
11. A nurse works in the rheumatology clinic and sees clients with rheumatoid arthritis (RA).
Which client
should the nurse see first?
a. Client who reports jaw pain when eating
b. Client with a red, hot, swollen right wrist
c. Client who has a puffy-looking area behind the knee
d. Client with a worse joint deformity since the last visit
12. A client with rheumatoid arthritis (RA) is on the postoperative nursing unit after having
elective surgery. The client reports that one arm feels like pins and needles and that the neck is very
painful since returning from
surgery. What action by the nurse is best?
a. Assist the client to change positions.
b. Document the findings in the clients chart.
c. Encourage range of motion of the neck.
d. Notify the provider immediately.
13. The nurse working in the rheumatology clinic is seeing clients with rheumatoid arthritis (RA).
What assessment would be most important for the client whose chart contains the diagnosis of
Sjgrens syndrome?
a. Abdominal assessment
b. Oxygen saturation
c. Renal function studies
d. Visual acuity
EXAM 1 211 – Test Bank Questions
14. The nurse is working with a client who has rheumatoid arthritis (RA). The nurse has identified
the priority problem of poor body image for the client. What finding by the nurse indicates goals
for this client problem are being met?
a. Attends meetings of a book club
b. Has a positive outlook on life
c. Takes medication as directed
d. Uses assistive devices to protect joints
15. A client is started on etanercept (Enbrel). What teaching by the nurse is most appropriate?
a. Giving subcutaneous injections
b. Having a chest x-ray once a year
c. Taking the medication with food
d. Using heat on the injection site
16. The nurse in the rheumatology clinic is assessing clients with rheumatoid arthritis (RA). Which
client should the nurse see first?
a. Client taking celecoxib (Celebrex) and ranitidine (Zantac)
b. Client taking etanercept (Enbrel) with a red injection site
c. Client with a blood glucose of 190 mg/dL who is taking steroids
d. Client with a fever and cough who is taking tofacitinib (Xeljanz)
17. A client with rheumatoid arthritis (RA) has an acutely swollen, red, and painful joint. What
nonpharmacologic treatment does the nurse apply?
a. Heating pad
b. Ice packs
c. Splints
d. Wax dip
18. The nurse on an inpatient rheumatology unit receives a hand-off report on a client with an
acute exacerbation of systemic lupus erythematosus (SLE). Which reported laboratory value
requires the nurse to assess the client further?
a. Creatinine: 3.9 mg/dL
b. Platelet count: 210,000/mm3
c. Red blood cell count: 5.2/mm3
d. White blood cell count: 4400/mm3
19. A client who has had systemic lupus erythematosus (SLE) for many years is in the clinic
reporting hip pain with ambulation. Which action by the nurse is best?
a. Assess medication records for steroid use.
b. Facilitate a consultation with physical therapy.
c. Measure the range of motion in both hips.
d. Notify the health care provider immediately.
20. A client with systemic lupus erythematosus (SLE) was recently discharged from the hospital
after an acute exacerbation. The client is in the clinic for a follow-up visit and is distraught about
the possibility of another hospitalization disrupting the family. What action by the nurse is best?
a. Explain to the client that SLE is an unpredictable disease.
b. Help the client create backup plans to minimize disruption.
c. Offer to talk to the family and educate them about SLE.
d. Tell the client to remain compliant with treatment plans.
EXAM 1 211 – Test Bank Questions
21. A nurse is caring for a client with systemic sclerosis. The clients facial skin is very taut, limiting
the clients ability to open the mouth. After consulting with a registered dietitian for appropriate
nutrition, what other consultation should the nurse facilitate?
a. Dentist
b. Massage therapist
c. Occupational therapy
d. Physical therapy
22. The nurse is teaching a client with gout dietary strategies to prevent exacerbations or other
problems. Which statement by the nurse is most appropriate?
a. Drink 1 to 2 liters of water each day.
b. Have 10 to 12 ounces of juice a day.
c. Liver is a good source of iron.
d. Never eat hard cheeses or sardines.
23. A nurse is teaching a client with psoriatic arthritis about the medication golimumab (Simponi).
What information is most important to include?
a. Avoid large crowds or people who are ill.
b. Stay upright for 1 hour after taking this drug.
c. This drug may cause your hair to fall out.
d. You may double the dose if pain is severe.
24. A client in the orthopedic clinic has a self-reported history of osteoarthritis. The client reports a
low-grade fever that started when the weather changed and several joints started acting up,
especially both hips and knees. What action by the nurse is best?
a. Assess the client for the presence of subcutaneous nodules or Bakers cysts.
b. Inspect the clients feet and hands for podagra and tophi on fingers and toes.
c. Prepare to teach the client about an acetaminophen (Tylenol) regimen.
d. Reassure the client that the problems will fade as the weather changes again.
25. A nurse is caring for a client after joint replacement surgery. What action by the nurse is most
important to prevent wound infection?
a. Assess the clients white blood cell count.
b. Culture any drainage from the wound.
c. Monitor the clients temperature every 4 hours.
d. Use aseptic technique for dressing changes.
26. A nurse is discharging a client after a total hip replacement. What statement by the client
indicates good potential for self-management?
a. I can bend down to pick something up.
b. I no longer need to do my exercises.
c. I will not sit with my legs crossed.
d. I wont wash my incision to keep it dry.
27. The nurse is caring for a client using a continuous passive motion (CPM) machine and has
delegated some tasks to the unlicensed assistive personnel (UAP). What action by the UAP warrants
intervention by the nurse?
a. Checking to see if the machine is working
b. Keeping controls in a secure place on the bed
c. Placing padding in the machine per request
d. Storing the CPM machine under the bed after removal
EXAM 1 211 – Test Bank Questions
28. A client recently diagnosed with systemic lupus erythematosus (SLE) is in the clinic for a followup visit. The nurse evaluates that the client practices good self-care when the client makes which
statement?
a. I always wear long sleeves, pants, and a hat when outdoors.
b. I try not to use cosmetics that contain any type of sunblock.
c. Since I tend to sweat a lot, I use a lot of baby powder.
d. Since I cant be exposed to the sun, I have been using a tanning bed.
29. A client is scheduled to have a hip replacement. Preoperatively, the client is found to be mildly
anemic and the surgeon states the client may need a blood transfusion during or after the surgery.
What action by the preoperative nurse is most important?
a. Administer preoperative medications as prescribed.
b. Ensure that a consent for transfusion is on the chart.
c. Explain to the client how anemia affects healing.
d. Teach the client about foods high in protein and iron.
30. An older client is scheduled to have hip replacement in 2 months and has the following
laboratory values: white blood cell count: 8900/mm3, red blood cell count: 3.2/mm3, hemoglobin: 9
g/dL, hematocrit: 32%. What intervention by the nurse is most appropriate?
a. Instruct the client to avoid large crowds.
b. Prepare to administer epoetin alfa (Epogen).
c. Teach the client about foods high in iron.
d. Tell the client that all laboratory results are normal.
31. A client is getting out of bed into the chair for the first time after an uncemented hip
replacement. What action by the nurse is most important?
a. Have adequate help to transfer the client.
b. Provide socks so the client can slide easier.
c. Tell the client full weight bearing is allowed.
d. Use a footstool to elevate the clients leg.
32. A client has fibromyalgia and is prescribed duloxetine hydrochloride (Cymbalta). The client
calls the clinic and asks the nurse why an antidepressant drug has been prescribed. What response
by the nurse is best?
a. A little sedation will help you get some rest.
b. Depression often accompanies fibromyalgia.
c. This drug works in the brain to decrease pain.
d. You will have more energy after taking this drug.
33. A client has been diagnosed with rheumatoid arthritis. The client has experienced increased
fatigue and worsening physical status and is finding it difficult to maintain the role of elder in his
cultural community. The elder is expected to attend social events and make community decisions.
Stress seems to exacerbate the condition. What action by the nurse is best?
a. Assess the clients culture more thoroughly.
b. Discuss options for performing duties.
c. See if the client will call a community meeting.
d. Suggest the client give up the role of elder.
EXAM 1 211 – Test Bank Questions
34. A client has rheumatoid arthritis that especially affects the hands. The client wants to finish
quilting a baby blanket before the birth of her grandchild. What response by the nurse is best?
a. Lets ask the provider about increasing your pain pills.
b. Hold ice bags against your hands before quilting.
c. Try a paraffin wax dip 20 minutes before you quilt.
d. You need to stop quilting before it destroys your fingers.
35. A client has newly diagnosed systemic lupus erythematosus (SLE). What instruction by the
nurse is most
important?
a. Be sure you get enough sleep at night.
b. Eat plenty of high-protein, high-iron foods.
c. Notify your provider at once if you get a fever.
d. Weigh yourself every day on the same scale.
36. A client comes to the family medicine clinic and reports joint pain and stiffness. The nurse is
asked to assess the client for Heberdens nodules. What assessment technique is correct?
a. Inspect the clients distal finger joints.
b. Palpate the clients abdomen for tenderness.
c. Palpate the clients upper body lymph nodes.
d. Perform range of motion on the clients wrists.
37. A client takes celecoxib (Celebrex) for chronic osteoarthritis in multiple joints. After a knee
replacement, the health care provider has prescribed morphine sulfate for postoperative pain relief.
The client also requests the celecoxib in addition to the morphine. What action by the nurse is best?
a. Consult with the health care provider about administering both drugs to the client.
b. Inform the client that the celecoxib will be started when he or she goes home.
c. Teach the client that, since morphine is stronger, celecoxib is not needed.
d. Tell the client he or she should not take both drugs at the same time.
MULTIPLE RESPONSE
1. The nursing student studying rheumatoid arthritis (RA) learns which facts about the disease?
(Select all that
apply.)
a. It affects single joints only.
b. Antibodies lead to inflammation.
c. It consists of an autoimmune process.
d. Morning stiffness is rare.
e. Permanent damage is inevitable.
2. A nurse is teaching a female client with rheumatoid arthritis (RA) about taking methotrexate
(MTX) (Rheumatrex) for disease control. What information does the nurse include? (Select all that
apply.)
a. Avoid acetaminophen in over-the-counter medications.
b. It may take several weeks to become effective on pain.
c. Pregnancy and breast-feeding are not affected by MTX.
d. Stay away from large crowds and people who are ill.
e. You may find that folic acid, a B vitamin, reduces side effects.
EXAM 1 211 – Test Bank Questions
3. A client has been diagnosed with fibromyalgia syndrome but does not want to take the prescribed
medications. What nonpharmacologic measures can the nurse suggest to help manage this
condition? (Select
all that apply.)
a. Acupuncture
b. Stretching
c. Supplements
d. Tai chi
e. Vigorous aerobics
4. The nurse working in the rheumatology clinic assesses clients with rheumatoid arthritis (RA) for
late manifestations. Which signs/symptoms are considered late manifestations of RA? (Select all
that apply.)
a. Anorexia
b. Feltys syndrome
c. Joint deformity
d. Low-grade fever
e. Weight loss
5. An older client returning to the postoperative nursing unit after a hip replacement is disoriented
and restless. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)?
(Select all that apply.)
a. Apply an abduction pillow to the clients legs.
b. Assess the skin under the abduction pillow straps.
c. Place pillows under the heels to keep them off the bed.
d. Monitor cognition to determine when the client can get up.
e. Take and record vital signs per unit/facility policy.
6. The nurse is working with clients who have connective tissue diseases. Which disorders are
correctly paired with their manifestations? (Select all that apply.)
a. Dry, scaly skin rash Systemic lupus erythematosus (SLE)
b. Esophageal dysmotility Systemic sclerosis
c. Excess uric acid excretion Gout
d. Footdrop and paresthesias Osteoarthritis
e. Vasculitis causing organ damage Rheumatoid arthritis
7. A nurse works with several clients who have gout. Which types of gout and their drug treatments
are correctly matched? (Select all that apply.)
a. Allopurinol (Zyloprim) Acute gout
b. Colchicine (Colcrys) Acute gout
c. Febuxostat (Uloric) Chronic gout
d. Indomethacin (Indocin) Acute gout
e. Probenecid (Benemid) Chronic gout
8. The nurse is caring for a client with systemic sclerosis (SSc). What comfort measures can the
nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Collaborate with a registered dietitian for appropriate foods.
b. Inspect the skin and note any areas of ulceration.
c. Keep the room at a comfortably warm temperature.
d. Place a foot cradle at the end of the bed to lift sheets.
e. Remind the client to elevate the head of the bed after eating.
EXAM 1 211 – Test Bank Questions
9. A client has rheumatoid arthritis (RA) and the visiting nurse is conducting a home assessment.
What options can the nurse suggest for the client to maintain independence in activities of daily
living (ADLs)? (Select all that apply.)
a. Grab bars to reach high items
b. Long-handled bath scrub brush
c. Soft rocker-recliner chair
d. Toothbrush with built-up handle
e. Wheelchair cushion for comfort
10. A home health care nurse is visiting a client discharged home after a hip replacement. The client
is still on partial weight bearing and using a walker. What safety precautions can the nurse
recommend to the client? (Select all that apply.)
a. Buy and install an elevated toilet seat.
b. Install grab bars in the shower and by the toilet.
c. Step into the bathtub with the affected leg first.
d. Remove all throw rugs throughout the house.
e. Use a shower chair while taking a shower.
11. A client with fibromyalgia is in the hospital for an unrelated issue. The client reports that sleep,
which is always difficult, is even harder now. What actions by the nurse are most appropriate?
(Select all that apply.)
a. Allow the client uninterrupted rest time.
b. Assess the clients usual bedtime routine.
c. Limit environmental noise as much as possible.
d. Offer a massage or warm shower at night.
e. Request an order for a strong sleeping pill.
12. A client has a possible connective tissue disease and the nurse is reviewing the clients laboratory
values. Which laboratory values and their related connective tissue diseases (CTDs) are correctly
matched? (Select all that apply.)
a. Elevated antinuclear antibody (ANA) Normal value; no connective tissue disease
b. Elevated sedimentation rate Rheumatoid arthritis
c. Lowered albumin Indicative only of nutritional deficit
d. Positive human leukocyte antigen B27 (HLA-B27) Reiters syndrome or ankylosing spondylitis
e. Positive rheumatoid factor Possible kidney disease
EXAM 1 211 – Test Bank Questions
Chapter 20: Care of Patients with Hypersensitivity (Allergy) and Autoimmunity
MULTIPLE CHOICE
1. A nurse works in an allergy clinic. What task performed by the nurse takes priority?
a. Checking emergency equipment each morning
b. Ensuring informed consent is obtained as needed
c. Providing educational materials in several languages
d. Teaching clients how to manage their allergies
2. A client is in the preoperative holding area prior to surgery. The nurse notes that the client has
allergies to avocados and strawberries. What action by the nurse is best?
a. Assess that the client has been NPO as directed.
b. Communicate this information with dietary staff.
c. Document the information in the clients chart.
d. Ensure the information is relayed to the surgical team.
3. The nurse is caring for clients on the medical-surgical unit. What action by the nurse will help
prevent a client from having a type II hypersensitivity reaction?
a. Administering steroids for severe serum sickness
b. Correctly identifying the client prior to a blood transfusion
c. Keeping the client free of the offending agent
d. Providing a latex-free environment for the client
4. A nurse suspects a client has serum sickness. What laboratory result would the nurse correlate
with this condition?
a. Blood urea nitrogen: 12 mg/dL
b. Creatinine: 3.2 mg/dL
c. Hemoglobin: 8.2 mg/dL
d. White blood cell count: 12,000/mm3
5. A client calls the clinic to report exposure to poison ivy and an itchy rash that is not helped with
over-the- counter antihistamines. What response by the nurse is most appropriate?
a. Antihistamines do not help poison ivy.
b. There are different antihistamines to try.
c. You should be seen in the clinic right away.
d. You will need to take some IV steroids.
6. A client with Sjgrens syndrome reports dry skin, eyes, mouth, and vagina. What
nonpharmacologic comfort measure does the nurse suggest?
a. Frequent eyedrops
b. Home humidifier
c. Strong moisturizer
d. Tear duct plugs
7. A client is receiving plasmapheresis as treatment for Goodpastures syndrome. When planning
care, the nurse places highest priority on interventions for which client problem?
a. Reduced physical activity related to the diseases effects on the lungs
b. Inadequate family coping related to the clients hospitalization
c. Inadequate knowledge related to the plasmapheresis process
d. Potential for infection related to the site for organism invasion
EXAM 1 211 – Test Bank Questions
8. A nurse has educated a client on an epinephrine auto-injector (EpiPen). What statement by the
client indicates additional instruction is needed?
a. I dont need to go to the hospital after using it.
b. I must carry two EpiPens with me at all times.
c. I will write the expiration date on my calendar.
d. This can be injected right through my clothes.
9. A client having severe allergy symptoms has received several doses of IV antihistamines. What
action by the nurse is most important?
a. Assess the clients bedside glucose reading.
b. Instruct the client not to get up without help.
c. Monitor the client frequently for tachycardia.
d. Record the clients intake, output, and weight.
10. A client is in the hospital and receiving IV antibiotics. When the nurse answers the clients call
light, the client presents an appearance as shown below:
What action by the nurse takes priority?
a. Administer epinephrine 1:1000, 0.3 mg IV push immediately.
b. Apply oxygen by facemask at 100% and a pulse oximeter.
c. Ensure a patent airway while calling the Rapid Response Team.
d. Reassure the client that these manifestations will go away.
MULTIPLE RESPONSE
1. The nursing student is studying hypersensitivity reactions. Which reactions are correctly
matched with their hypersensitivity types? (Select all that apply.)
a. Type I Examples include hay fever and anaphylaxis
b. Type II Mediated by action of immunoglobulin M (IgM)
c. Type III Immune complex deposits in blood vessel walls
d. Type IV Examples are poison ivy and transplant rejection
e. Type V Examples include a positive tuberculosis test and sarcoidosis
2. A client in the family practice clinic reports a 2-week history of an allergy to something. The
nurse obtains the following assessment and laboratory data:
Physical Assessment Data Laboratory Results
Reports sore throat, runny nose, headache
Posterior pharynx is reddened
Nasal discharge is seen in the back of the throat
Nasal discharge is creamy yellow in color
Temperature 100.2 F (37.9 C)
Red, watery eyes White blood cell count: 13,400/mm3
Eosinophil count: 11.5%
Neutrophil count: 82%
About what medications and interventions does the nurse plan to teach this client? (Select all that
apply.)
a. Elimination of any pets
b. Chlorpheniramine (Chlor-Trimaton)
c. Future allergy scratch testing
d. Proper use of decongestant nose sprays
e. Taking the full dose of antibiotics
EXAM 1 211 – Test Bank Questions
Chapter 22: Care of Patients with Cancer
MULTIPLE CHOICE
1. A nurse in the oncology clinic is providing preoperative education to a client just diagnosed with
cancer. The client has been scheduled for surgery in 3 days. What action by the nurse is best?
a. Call the client at home the next day to review teaching.
b. Give the client information about a cancer support group.
c. Provide all the preoperative instructions in writing.
d. Reassure the client that surgery will be over soon.
2. A nurse reads on a hospitalized clients chart that the client is receiving teletherapy. What action
by the nurse is best?
a. Coordinate continuation of the therapy.
b. Place the client on radiation precautions.
c. No action by the nurse is needed at this time.
d. Restrict visitors to only adults over age 18.
3. A new nurse has been assigned a client who is in the hospital to receive iodine-131 treatment.
Which action by the nurse is best?
a. Ensure the client is placed in protective isolation.
b. Hand off a pregnant client to another nurse.
c. No special action is necessary to care for this client.
d. Read the policy on handling radioactive excreta.
4. A client in the oncology clinic reports her family is frustrated at her ongoing fatigue 4 months
after radiation therapy for breast cancer. What response by the nurse is most appropriate?
a. Are you getting adequate rest and sleep each day?
b. It is normal to be fatigued even for years afterward.
c. This is not normal and Ill let the provider know.
d. Try adding more vitamins B and C to your diet.
5. A client tells the oncology nurse about an upcoming vacation to the beach to celebrate completing
radiation treatments for cancer. What response by the nurse is most appropriate?
a. Avoid getting salt water on the radiation site.
b. Do not expose the radiation area to direct sunlight.
c. Have a wonderful time and enjoy your vacation!
d. Remember you should not drink alcohol for a year.
6. A client is receiving chemotherapy through a peripheral IV line. What action by the nurse is
most important?
a. Assessing the IV site every hour
b. Educating the client on side effects
c. Monitoring the client for nausea
d. Providing warm packs for comfort
7. A client with cancer is admitted to a short-term rehabilitation facility. The nurse prepares to
administer the clients oral chemotherapy medications. What action by the nurse is most
appropriate?
a. Crush the medications if the client cannot swallow them.
b. Give one medication at a time with a full glass of water.
c. No special precautions are needed for these medications.
d. Wear personal protective equipment when handling the medications.
EXAM 1 211 – Test Bank Questions
8. The nurse working with oncology clients understands that which age-related change increases
the older clients susceptibility to infection during chemotherapy?
a. Decreased immune function
b. Diminished nutritional stores
c. Existing cognitive deficits
d. Poor physical reserves
9. After receiving the hand-off report, which client should the oncology nurse see first?
a. Client who is afebrile with a heart rate of 108 beats/min
b. Older client on chemotherapy with mental status changes
c. Client who is neutropenic and in protective isolation
d. Client scheduled for radiation therapy today
10. A client has a platelet count of 9800/mm3. What action by the nurse is most appropriate?
a. Assess the client for calf pain, warmth, and redness.
b. Instruct the client to call for help to get out of bed.
c. Obtain cultures as per the facilitys standing policy.
d. Place the client on protective isolation precautions.
11. A client hospitalized for chemotherapy has a hemoglobin of 6.1 mg/dL. What medication should
the nurse prepare to administer?
a. Epoetin alfa (Epogen)
b. Filgrastim (Neupogen)
c. Mesna (Mesnex)
d. Oprelvekin (Neumega)
12. A nurse works with clients who have alopecia from chemotherapy. What action by the nurse
takes priority?
a. Helping clients adjust to their appearance
b. Reassuring clients that this change is temporary
c. Referring clients to a reputable wig shop
d. Teaching measures to prevent scalp injury
13. A client is receiving interleukins along with chemotherapy. What assessment by the nurse takes
priority?
a. Blood pressure
b. Lung assessment
c. Oral mucous membranes
d. Skin integrity
14. A client is receiving rituximab (Rituxan) and asks how it works. What response by the nurse is
best?
a. It causes rapid lysis of the cancer cell membranes.
b. It destroys the enzymes needed to create cancer cells.
c. It prevents the start of cell division in the cancer cells.
d. It sensitizes certain cancer cells to chemotherapy.
15. Four clients are receiving tyrosine kinase inhibitors (TKIs). Which of these four clients should
the nurse assess first?
a. Client with dry, itchy, peeling skin
b. Client with a serum calcium of 9.2 mg/dL
c. Client with a serum potassium of 2.8 mEq/L
d. Client with a weight gain of 0.5 pound (1.1 kg) in 1 day
EXAM 1 211 – Test Bank Questions
16. A nurse is assessing a female client who is taking progestins. What assessment finding requires
the nurse to notify the provider immediately?
a. Irregular menses
b. Edema in the lower extremities
c. Ongoing breast tenderness
d. Red, warm, swollen calf
17. A client with a history of prostate cancer is in the clinic and reports new onset of severe low
back pain. What action by the nurse is most important?
a. Assess the clients gait and balance.
b. Ask the client about the ease of urine flow.
c. Document the report completely.
d. Inquire about the clients job risks.
18. The nurse has taught a client with cancer ways to prevent infection. What statement by the
client indicates that more teaching is needed?
a. I should take my temperature daily and when I dont feel well.
b. I will wash my toothbrush in the dishwasher once a week.
c. I wont let anyone share any of my personal items or dishes.
d. Its alright for me to keep my pets and change the litter box.
19. A client has received a dose of ondansetron (Zofran) for nausea. What action by the nurse is
most important?
a. Assess the client for a headache.
b. Assist the client in getting out of bed.
c. Instruct the client to reduce salt intake. D
d. Weigh the client daily before the client eats.
20. A nurse working with clients who experience alopecia knows that which is the best method of
helping clients manage the psychosocial impact of this problem?
a. Assisting the client to pre-plan for this event
b. Reassuring the client that alopecia is temporary
c. Teaching the client ways to protect the scalp
d. Telling the client that there are worse side effects
21. A client is admitted with superior vena cava syndrome. What action by the nurse is most
appropriate?
a. Administer a dose of allopurinol (Aloprim).
b. Assess the clients serum potassium level.
c. Gently inquire about advance directives.
d. Prepare the client for emergency surgery.
22. A client is having a catheter placed in the femoral artery to deliver yttrium-90 beads into a liver
tumor. What action by the nurse is most important?
a. Assessing the clients abdomen beforehand
b. Ensuring that informed consent is on the chart
c. Marking the clients bilateral pedal pulses
d. Reviewing client teaching done previously
EXAM 1 211 – Test Bank Questions
23. A nurse works on an oncology unit and delegates personal hygiene to an unlicensed assistive
personnel (UAP). What action by the UAP requires intervention from the nurse?
a. Allowing a very tired client to skip oral hygiene and sleep
b. Assisting clients with washing the perianal area every 12 hours
c. Helping the client use a soft-bristled toothbrush for oral care
d. Reminding the client to rinse the mouth with water or saline
24. A client with cancer has anorexia and mucositis, and is losing weight. The clients family
members continually bring favorite foods to the client and are distressed when the client wont eat
them. What action by the nurse is best?
a. Explain the pathophysiologic reasons behind the client not eating.
b. Help the family show other ways to demonstrate love and caring.
c. Suggest foods and liquids the client might be willing to try to eat.
d. Tell the family the client isnt able to eat now no matter what they bring.
25. A client in the emergency department reports difficulty breathing. The nurse assesses the clients
appearance as depicted below:
What action by the nurse is the priority?
a. Assess blood pressure and pulse.
b. Attach the client to a pulse oximeter.
c. Have the client rate his or her pain.
d. Start high-dose steroid therapy.
MULTIPLE RESPONSE
1. The student nurse caring for clients who have cancer understands that the general consequences
of cancer include which client problems? (Select all that apply.)
a. Clotting abnormalities from thrombocythemia
b. Increased risk of infection from white blood cell deficits
c. Nutritional deficits such as early satiety and cachexia
d. Potential for reduced gas exchange
e. Various motor and sensory deficits
2. A nurse is preparing to administer IV chemotherapy. What supplies does this nurse need? (Select
all that apply.)
a. Chemo gloves
b. Facemask
c. Isolation gown
d. N95 respirator
e. Shoe covers
3. A client on interferon therapy is reporting severe skin itching and irritation. What actions does
the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Apply moisturizers to dry skin.
b. Apply steroid creams to the skin.
c. Bathe the client using mild soap.
d. Help the client with a hot water bath.
e. Teach the client to avoid sunlight.
EXAM 1 211 – Test Bank Questions
4. A client has thrombocytopenia. What actions does the nurse delegate to the unlicensed assistive
personnel (UAP)? (Select all that apply.)
a. Apply the clients shoes before getting the client out of bed.
b. Assist the client with ambulation.
c. Shave the client with a safety razor only.
d. Use a lift sheet to move the client up in bed.
e. Use the Waterpik on a low setting for oral care.
5. A client has mucositis. What actions by the nurse will improve the clients nutrition? (Select all
that apply.)
a. Assist with rinsing the mouth with saline frequently.
b. Encourage the client to eat room-temperature foods.
c. Give the client hot liquids to hold in the mouth.
d. Provide local anesthetic medications to swish and spit.
e. Remind the client to brush teeth gently after each meal.
6. A clients family members are concerned that telling the client about a new finding of cancer will
cause extreme emotional distress. They approach the nurse and ask if this can be kept from the
client. What actions by the nurse are most appropriate? (Select all that apply.)
a. Ask the family to describe their concerns more fully.
b. Consult with a social worker, chaplain, or ethics committee.
c. Explain the clients right to know and ask for their assistance.
d. Have the unit manager take over the care of this client and family. e. Tell the family that this secret will
not be kept from the client.
7. A client receiving chemotherapy has a white blood cell count of 1000/mm3. What actions by the
nurse are most appropriate? (Select all that apply.)
a. Assess all mucous membranes every 4 to 8 hours.
b. Do not allow the client to eat meat or poultry.
c. Listen to lung sounds and monitor for cough.
d. Monitor the venous access device appearance with vital signs.
e. Take and record vital signs every 4 to 8 hours.
EXAM 1 211 – Test Bank Questions
Chapter 26: Care of Patients with Burns
MULTIPLE CHOICE
1. The registered nurse assigns a client who has an open burn wound to a licensed practical nurse
(LPN). Which instruction should the nurse provide to the LPN when assigning this client?
a. Administer the prescribed tetanus toxoid vaccine.
b. Assess the clients wounds for signs of infection.
c. Encourage the client to breathe deeply every hour.
d. Wash your hands on entering the clients room.
2. The nurse is caring for a client with an acute burn injury. Which action should the nurse take to
prevent infection by autocontamination?
a. Use a disposable blood pressure cuff to avoid sharing with other clients.
b. Change gloves between wound care on different parts of the clients body.
c. Use the closed method of burn wound management for all wound care.
d. Advocate for proper and consistent handwashing by all members of the staff.
3. The nurse teaches burn prevention to a community group. Which statement by a member of the
group should cause the nurse the greatest concern?
a. I get my chimney swept every other year.
b. My hot water heater is set at 120 degrees.
c. Sometimes I wake up at night and smoke.
d. I use a space heater when it gets below zero.
4. A nurse cares for a client who has facial burns. The client asks, Will I ever look the same? How
should the nurse respond?
a. With reconstructive surgery, you can look the same.
b. We can remove the scars with the use of a pressure dressing.
c. You will not look exactly the same but cosmetic surgery will help.
d. You shouldnt start worrying about your appearance right now.
5. A nurse assesses a client who has a burn injury. Which statement indicates the client has a
positive perspective of his or her appearance?
a. I will allow my spouse to change my dressings.
b. I want to have surgical reconstruction.
c. I will bathe and dress before breakfast.
d. I have secured the pressure dressings as ordered.
6. The nurse assesses a client who has a severe burn injury. Which statement indicates the client
understands the psychosocial impact of a severe burn injury?
a. It is normal to feel some depression.
b. I will go back to work immediately.
c. I will not feel anger about my situation.
d. Once I get home, things will be normal.
7. An emergency room nurse assesses a client who was rescued from a home fire. The client
suddenly develops a loud, brassy cough. Which action should the nurse take first?
a. Apply oxygen and continuous pulse oximetry.
b. Provide small quantities of ice chips and sips of water.
c. Request a prescription for an antitussive medication.
d. Ask the respiratory therapist to provide humidified air.
EXAM 1 211 – Test Bank Questions
8. A nurse prepares to administer intravenous cimetidine (Tagamet) to a client who has a new burn
injury. The client asks, Why am I taking this medication? How should the nurse respond?
a. Tagamet stimulates intestinal movement so you can eat more.
b. It improves fluid retention, which helps prevent hypovolemic shock.
c. It helps prevent stomach ulcers, which are common after burns.
d. Tagamet protects the kidney from damage caused by dehydration.
9. A nurse cares for a client with a burn injury who presents with drooling and difficulty
swallowing. Which action should the nurse take first?
a. Assess the level of consciousness and pupillary reactions.
b. Ascertain the time food or liquid was last consumed.
c. Auscultate breath sounds over the trachea and bronchi.
d. Measure abdominal girth and auscultate bowel sounds.
10. A nurse receives new prescriptions for a client with severe burn injuries who is receiving fluid
resuscitation per the Parkland formula. The clients urine output continues to range from 0.2 to 0.25
mL/kg/hr. Which prescription should the nurse question?
a. Increase intravenous fluids by 100 mL/hr.
b. Administer furosemide (Lasix) 40 mg IV push.
c. Continue to monitor urine output hourly.
d. Draw blood for serum electrolytes STAT.
11. A nurse reviews the laboratory results for a client who was burned 24 hours ago. Which
laboratory result should the nurse report to the health care provider immediately?
a. Arterial pH: 7.32
b. Hematocrit: 52%
c. Serum potassium: 6.5 mEq/L
d. Serum sodium: 131 mEq/L
12. A nurse assesses a client who has burn injuries and notes crackles in bilateral lung bases, a
respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. Which action
should the nurse take next?
a. Administer furosemide (Lasix).
b. Perform chest physiotherapy.
c. Document and reassess in an hour.
d. Place the client in an upright position.
13. A nurse cares for a client who has burn injuries. The clients wife asks, When will his high risk
for infection decrease? How should the nurse respond?
a. When the antibiotic therapy is complete.
b. As soon as his albumin levels return to normal.
c. Once we complete the fluid resuscitation process.
d. When all of his burn wounds have closed.
14. A nurse administers topical gentamicin sulfate (Garamycin) to a clients burn injury. Which
laboratory value should the nurse monitor while the client is prescribed this therapy?
a. Creatinine
b. Red blood cells
c. Sodium
d. Magnesium
EXAM 1 211 – Test Bank Questions
15. A nurse cares for a client with burn injuries. Which intervention should the nurse implement to
appropriately reduce the clients pain?
a. Administer the prescribed intravenous morphine sulfate.
b. Apply ice to skin around the burn wound for 20 minutes.
c. Administer prescribed intramuscular ketorolac (Toradol).
d. Decrease tactile stimulation near the burn injuries.
16. A nurse cares for a client with burn injuries from a house fire. The client is not consistently
oriented and reports a headache. Which action should the nurse take?
a. Increase the clients oxygen and obtain blood gases.
b. Draw blood for a carboxyhemoglobin level.
c. Increase the clients intravenous fluid rate.
d. Perform a thorough Mini-Mental State Examination.
17. A nurse teaches a client being treated for a full-thickness burn. Which statement should the
nurse include in this clients discharge teaching?
a. You should change the batteries in your smoke detector once a year.
b. Join a program that assists burn clients to reintegration into the community.
c. I will demonstrate how to change your wound dressing for you and your family.
d. Let me tell you about the many options available to you for reconstructive surgery.
18. A nurse assesses bilateral wheezes in a client with burn injuries inside the mouth. Four hours
later the wheezing is no longer heard. Which action should the nurse take?
a. Document the findings and reassess in 1 hour.
b. Loosen any constrictive dressings on the chest.
c. Raise the head of the bed to a semi-Fowlers position.
d. Gather appropriate equipment and prepare for an emergency airway.
19. A nurse uses the rule of ninesto assess a client with burn injuries to the entire back region and
left arm. How should the nurse document the percentage of the clients body that sustained burns?
a. 9%
b. 18%
c. 27%
d. 36%
20. A nurse assesses a client admitted with deep partial-thickness and full-thickness burns on the
face, arms, and chest. Which assessment finding should alert the nurse to a potential complication?
a. Partial pressure of arterial oxygen (PaO2) of 80 mm Hg
b. Urine output of 20 mL/hr
c. Productive cough with white pulmonary secretions
d. Core temperature of 100.6 F (38 C)
21. A nurse delegates hydrotherapy to an unlicensed assistive personnel (UAP). Which statement
should the nurse include when delegating this activity?
a. Keep the water temperature constant when showering the client.
b. Assess the wound beds during the hydrotherapy treatment.
c. Apply a topical enzyme agent after bathing the client.
d. Use sterile saline to irrigate and clean the clients wounds.
EXAM 1 211 – Test Bank Questions
22. A nurse reviews the following data in the chart of a client with burn injuries:
Admission Notes:
36-year-old female with bilateral leg burns
NKDA
Health history of asthma and seasonal allergies
Wound Assessment:
Bilateral leg burns present with a white and leatherlike appearance.
No blisters or bleeding present.
Client rates pain 2/10 on a scale of 0-10.
Based on the data provided, how should the nurse categorize this clients injuries?
a. Partial-thickness deep
b. Partial-thickness superficial
c. Full thickness
d. Superficial
23. After assessing an older adult client with a burn wound, the nurse documents the findings as
follows:
Vital Signs:
Heart rate: 110 beats/min
Blood pressure: 112/68 mmHg
Respiratory rate: 20 breaths/min
Oxygen saturation: 94%
Pain: 3/10 present
Laboratory Results:
Red blood cell count: 5,000,000/mm3
White blood cell count: 10,000/mm3
Platelet count: 200,000/mm3
Wound Assessment:
Left chest burn wound, 3cm 2.5 cm 0.5 cm
wound bed pale
surrounding tissues with edema
Based on the documented data, which action should the nurse take next?
a. Assess the clients skin for signs of adequate perfusion.
b. Calculate intake and output ratio for the last 24 hours.
c. Prepare to obtain blood and wound cultures.
d. Place the client in an isolation room.
MULTIPLE RESPONSE
1. A nurse cares for a client with burn injuries during the resuscitation phase. Which actions are
priorities during this phase? (Select all that apply.)
a. Administer analgesics.
b. Prevent wound infections.
c. Provide fluid replacement.
d. Decrease core temperature.
e. Initiate physical therapy.
EXAM 1 211 – Test Bank Questions
2. A nurse cares for a client with burn injuries who is experiencing anxiety and pain. Which
nonpharmacologic comfort measures should the nurse implement? (Select all that apply.)
a. Music as a distraction
b. Tactile stimulation
c. Massage to injury sites
d. Cold compresses
e. Increasing client control
3. A nurse plans care for a client with burn injuries. Which interventions should the nurse include
in this clients plan of care to ensure adequate nutrition? (Select all that apply.)
a. Provide at least 5000 kcal/day.
b. Start an oral diet on the first day.
c. Administer a diet high in protein.
d. Collaborate with a registered dietitian.
e. Offer frequent high-calorie snacks.
4. A nurse cares for an older client with burn injuries. Which age-related changes are paired
appropriately with their complications from the burn injuries? (Select all that apply.)
a. Slower healing time Increased risk for loss of function from contracture formation
b. Reduced inflammatory response Deep partial-thickness wound with minimal exposure
c. Reduced thoracic compliance Increased risk for atelectasis
d. High incidence of cardiac impairments Increased risk for acute kidney injury
e. Thinner skin May not exhibit a fever when infection is present
5. A nurse plans care for a client with burn injuries. Which interventions should the nurse
implement to prevent infection in the client? (Select all that apply.)
a. Ask all family members and visitors to perform hand hygiene before touching the client.
b. Carefully monitor burn wounds when providing each dressing change.
Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 210
c. Clean equipment with alcohol between uses with each client on the unit.
d. Allow family members to only bring the client plants from the hospitals gift shop.
e. Use aseptic technique and wear gloves when performing wound care.
EXAM 1 211 – Test Bank Questions
Chapter 37: Care of Patients with Shock
MULTIPLE CHOICE
1. A student is caring for a client who suffered massive blood loss after trauma. How does the
student correlate the blood loss with the clients mean arterial pressure (MAP)?
a. It causes vasoconstriction and increased MAP.
b. Lower blood volume lowers MAP.
c. There is no direct correlation to MAP.
d. It raises cardiac output and MAP.
2. A nurse is caring for a client after surgery. The clients respiratory rate has increased from 12 to
18 breaths/min and the pulse rate increased from 86 to 98 beats/min since they were last assessed 4
hours ago. What action by the nurse is best?
a. Ask if the client needs pain medication.
b. Assess the clients tissue perfusion further.
c. Document the findings in the clients chart.
d. Increase the rate of the clients IV infusion.
3. The nurse gets the hand-off report on four clients. Which client should the nurse assess first?
a. Client with a blood pressure change of 128/74 to 110/88 mm Hg
b. Client with oxygen saturation unchanged at 94%
c. Client with a pulse change of 100 to 88 beats/min
d. Client with urine output of 40 mL/hr for the last 2 hours
4. A nurse is caring for a client after surgery who is restless and apprehensive. The unlicensed
assistive personnel (UAP) reports the vital signs and the nurse sees they are only slightly different
from previous readings. What action does the nurse delegate next to the UAP?
a. Assess the client for pain or discomfort.
b. Measure urine output from the catheter.
c. Reposition the client to the unaffected side.
d. Stay with the client and reassure him or her.
5. A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of
208 mg/dL. The spouse asks why the client needs insulin as the client is not a diabetic. What
response by the nurse is best?
a. High glucose is common in shock and needs to be treated.
b. Some of the medications we are giving are to raise blood sugar.
c. The IV solution has lots of glucose, which raises blood sugar.
d. The stress of this illness has made your spouse a diabetic.
6. A nurse caring for a client notes the following assessments: white blood cell count 3800/mm3,
blood glucose level 198 mg/dL, and temperature 96.2 F (35.6 C). What action by the nurse takes
priority?
a. Document the findings in the clients chart.
b. Give the client warmed blankets for comfort.
c. Notify the health care provider immediately.
d. Prepare to administer insulin per sliding scale.
7. A nurse works at a community center for older adults. What self-management measure can the
nurse teach the clients to prevent shock?
a. Do not get dehydrated in warm weather.
b. Drink fluids on a regular schedule.
c. Seek attention for any lacerations.
d. Take medications as prescribed.
EXAM 1 211 – Test Bank Questions
8. A client arrives in the emergency department after being in a car crash with fatalities. The client
has a nearly amputated leg that is bleeding profusely. What action by the nurse takes priority?
a. Apply direct pressure to the bleeding.
b. Ensure the client has a patent airway.
c. Obtain consent for emergency surgery.
d. Start two large-bore IV catheters.
9. A client is receiving norepinephrine (Levophed) for shock. What assessment finding best
indicates a therapeutic effect from this drug?
a. Alert and oriented, answering questions
b. Client denial of chest pain or chest pressure
c. IV site without redness or swelling
d. Urine output of 30 mL/hr for 2 hours
10. A student nurse is caring for a client who will be receiving sodium nitroprusside (Nipride) via
IV infusion. What action by the student causes the registered nurse to intervene?
a. Assessing the IV site before giving the drug
b. Obtaining a programmable (smart) IV pump
c. Removing the IV bag from the brown plastic cover
d. Taking and recording a baseline set of vital signs
11. A client has been brought to the emergency department after being shot multiple times. What
action should the nurse perform first?
a. Apply personal protective equipment.
b. Notify local law enforcement officials.
c. Obtain universal donor blood.
d. Prepare the client for emergency surgery.
12. A nurse is caring for several clients at risk for shock. Which laboratory value requires the nurse
to communicate with the health care provider?
a. Creatinine: 0.9 mg/dL
b. Lactate: 6 mmol/L
c. Sodium: 150 mEq/L
d. White blood cell count: 11,000/mm3
13. A client in shock is apprehensive and slightly confused. What action by the nurse is best?
a. Offer to remain with the client for awhile.
b. Prepare to administer antianxiety medication.
c. Raise all four siderails on the clients bed.
d. Tell the client everything possible is being done.
14. A client is being discharged home after a large myocardial infarction and subsequent coronary
artery bypass grafting surgery. The clients sternal wound has not yet healed. What statement by
the client most indicates a higher risk of developing sepsis after discharge?
a. All my friends and neighbors are planning a party for me.
b. I hope I can get my water turned back on when I get home.
c. I am going to have my daughter scoop the cat litter box.
d. My grandkids are so excited to have me coming home!
EXAM 1 211 – Test Bank Questions
15. A client in shock has been started on dopamine. What assessment finding requires the nurse to
communicate with the provider immediately?
a. Blood pressure of 98/68 mm Hg
b. Pedal pulses 1+/4+ bilaterally
c. Report of chest heaviness
d. Urine output of 32 mL/hr
MULTIPLE RESPONSE
1. The student nurse studying shock understands that the common manifestations of this condition
are directly related to which problems? (Select all that apply.)
a. Anaerobic metabolism
b. Hyperglycemia
c. Hypotension
d. Impaired renal perfusion
e. Increased perfusion
2. The nurse caring for hospitalized clients includes which actions on their care plans to reduce the
possibility of the clients developing shock? (Select all that apply.)
a. Assessing and identifying clients at risk
b. Monitoring the daily white blood cell count
c. Performing proper hand hygiene
d. Removing invasive lines as soon as possible
e. Using aseptic technique during procedures
3. The nurse caring frequently for older adults in the hospital is aware of risk factors that place
them at a higher risk for shock. For what factors would the nurse assess? (Select all that apply.)
a. Altered mobility/immobility
b. Decreased thirst response
c. Diminished immune response
d. Malnutrition
e. Overhydration
4. A client is in the early stages of shock and is restless. What comfort measures does the nurse
delegate to the nursing student? (Select all that apply.)
a. Bringing the client warm blankets
b. Giving the client hot tea to drink
c. Massaging the clients painful legs
d. Reorienting the client as needed
e. Sitting with the client for reassurance
5. The nurse is caring for a client with suspected severe sepsis. What does the nurse prepare to do
within 3 hours of the client being identified as being at risk? (Select all that apply.)
a. Administer antibiotics.
b. Draw serum lactate levels.
c. Infuse vasopressors.
d. Measure central venous pressure.
e. Obtain blood cultures.
EXAM 1 211 – Test Bank Questions
Chapter 40: Care of Patients with Hematologic Problems
MULTIPLE CHOICE
1. A nurse caring for a client with sickle cell disease (SCD) reviews the clients laboratory work.
Which finding should the nurse report to the provider?
a. Creatinine: 2.9 mg/dL
b. Hematocrit: 30%
c. Sodium: 147 mEq/L
d. White blood cell count: 12,000/mm3
2. A client hospitalized with sickle cell crisis frequently asks for opioid pain medications, often
shortly afterreceiving a dose. The nurses on the unit believe the client is drug seeking. When the
client requests pain medication, what action by the nurse is best?
a. Give the client pain medication if it is time for another dose.
b. Instruct the client not to request pain medication too early.
c. Request the provider leave a prescription for a placebo.
d. Tell the client it is too early to have more pain medication.
3. A client in sickle cell crisis is dehydrated and in the emergency department. The nurse plans to
start an IV. Which fluid choice is best?
a. 0.45% normal saline
b. 0.9% normal saline
c. Dextrose 50% (D50)
d. Lactated Ringers solution
4. A client presents to the emergency department in sickle cell crisis. What intervention by the
nurse takes priority?
a. Administer oxygen.
b. Apply an oximetry probe.
c. Give pain medication.
d. Start an IV line.
5. A client has a serum ferritin level of 8 ng/mL and microcytic red blood cells. What action by the
nurse is best?
a. Encourage high-protein foods.
b. Perform a Hemoccult test on the clients stools.
c. Offer frequent oral care.
d. Prepare to administer cobalamin (vitamin B12).
6. A client has Crohns disease. What type of anemia is this client most at risk for developing?
a. Folic acid deficiency
b. Fanconis anemia
c. Hemolytic anemia
d. Vitamin B12 anemia
7. A nurse in a hematology clinic is working with four clients who have polycythemia vera. Which
client should the nurse see first?
a. Client with a blood pressure of 180/98 mm Hg
b. Client who reports shortness of breath
c. Client who reports calf tenderness and swelling
d. Client with a swollen and painful left great toe
EXAM 1 211 – Test Bank Questions
8. A nursing student is caring for a client with leukemia. The student asks why the client is still at
risk forinfection when the clients white blood cell count (WBC) is high. What response by the
registered nurse is best?
a. If the WBCs are high, there already is an infection present.
b. The client is in a blast crisis and has too many WBCs.
c. There must be a mistake; the WBCs should be very low.
d. Those WBCs are abnormal and dont provide protection.
9. The family of a neutropenic client reports the client is not acting right. What action by the nurse
is the priority?
a. Ask the client about pain.
b. Assess the client for infection.
c. Delegate taking a set of vital signs.
d. Look at todays laboratory results.
10. A nurse is caring for a client who is about to receive a bone marrow transplant. To best help the
client cope with the long recovery period, what action by the nurse is best?
a. Arrange a visitation schedule among friends and family.
b. Explain that this process is difficult but must be endured.
c. Help the client find things to hope for each day of recovery.
d. Provide plenty of diversionary activities for this time.
11. A nursing student is struggling to understand the process of graft-versus-host disease. What
explanation by the nurse instructor is best?
a. Because of immunosuppression, the donor cells take over.
b. Its like a transfusion reaction because no perfect matches exist.
c. The clients cells are fighting donor cells for dominance.
d. The donors cells are actually attacking the clients cells.
12. The nurse is caring for a client with leukemia who has the priority problem of fatigue. What
action by the client best indicates that an important goal for this problem has been met?
a. Doing activities of daily living (ADLs) using rest periods
b. Helping plan a daily activity schedule
c. Requesting a sleeping pill at night
d. Telling visitors to leave when fatigued
13. A nurse is caring for a young male client with lymphoma who is to begin treatment. What
teaching topic is a priority?
a. Genetic testing
b. Infection prevention
c. Sperm banking
d. Treatment options
14. A client has been admitted after sustaining a humerus fracture that occurred when picking up
the family cat. What test result would the nurse correlate to this condition?
a. Bence-Jones protein in urine
b. Epstein-Barr virus: positive
c. Hemoglobin: 18 mg/dL
d. Red blood cell count: 8.2/mm3
EXAM 1 211 – Test Bank Questions
15. A client with multiple myeloma demonstrates worsening bone density on diagnostic scans.
About what drug does the nurse plan to teach this client?
a. Bortezomib (Velcade)
b. Dexamethasone (Decadron)
c. Thalidomide (Thalomid)
d. Zoledronic acid (Zometa)
16. A client with autoimmune idiopathic thrombocytopenic purpura (ITP) has had a splenectomy
and returned to the surgical unit 2 hours ago. The nurse assesses the client and finds the abdominal
dressing saturated with blood. What action is most important?
a. Preparing to administer a blood transfusion
b. Reinforcing the dressing and documenting findings
c. Removing the dressing and assessing the surgical site
d. Taking a set of vital signs and notifying the surgeon
17. A client has a platelet count of 9000/mm3. The nurse finds the client confused and mumbling.
What action takes priority?
a. Calling the Rapid Response Team
b. Delegating taking a set of vital signs
c. Instituting bleeding precautions
d. Placing the client on bedrest
18. A nurse is preparing to administer a blood transfusion. What action is most important?
a. Correctly identifying client using two identifiers
b. Ensuring informed consent is obtained if required
c. Hanging the blood product with Ringers lactate
d. Staying with the client for the entire transfusion
19. A nurse is preparing to hang a blood transfusion. Which action is most important?
a. Documenting the transfusion
b. Placing the client on NPO status
c. Placing the client in isolation
d. Putting on a pair of gloves
20. A client receiving a blood transfusion develops anxiety and low back pain. After stopping the
transfusion, what action by the nurse is most important?
a. Documenting the events in the clients medical record
b. Double-checking the client and blood product identification
c. Placing the client on strict bedrest until the pain subsides
d. Reviewing the clients medical record for known allergies
21. A client has thrombocytopenia. What client statement indicates the client understands selfmanagement of this condition?
a. I brush and use dental floss every day.
b. I chew hard candy for my dry mouth.
c. I usually put ice on bumps or bruises.
d. Nonslip socks are best when I walk.
22. A client has a sickle cell crisis with extreme lower extremity pain. What comfort measure does
the nurse delegate to the unlicensed assistive personnel (UAP)?
a. Apply ice packs to the clients legs.
b. Elevate the clients legs on pillows.
c. Keep the lower extremities warm.
d. Place elastic bandage wraps on the clients legs.
EXAM 1 211 – Test Bank Questions
23. A client admitted for sickle cell crisis is distraught after learning her child also has the disease.
What response by the nurse is best?
a. Both you and the father are equally responsible for passing it on.
b. I can see you are upset. I can stay here with you a while if you like.
c. Its not your fault; there is no way to know who will have this disease.
d. There are many good treatments for sickle cell disease these days.
24. A client with sickle cell disease (SCD) takes hydroxyurea (Droxia). The client presents to the
clinic reporting an increase in fatigue. What laboratory result should the nurse report
immediately?
a. Hematocrit: 25%
b. Hemoglobin: 9.2 mg/dL
c. Potassium: 3.2 mEq/L
d. White blood cell count: 38,000/mm3
25. A nurse is caring for four clients with leukemia. After hand-off report, which client should the
nurse see first?
a. Client who had two bloody diarrhea stools this morning
b. Client who has been premedicated for nausea prior to chemotherapy
c. Client with a respiratory rate change from 18 to 22 breaths/min
d. Client with an unchanged lesion to the lower right lateral malleolus
26. A client has frequent hospitalizations for leukemia and is worried about functioning as a parent
to four small children. What action by the nurse would be most helpful?
a. Assist the client to make sick day plans for household responsibilities.
b. Determine if there are family members or friends who can help the client.
c. Help the client inform friends and family that they will have to help out.
d. Refer the client to a social worker in order to investigate respite child care.
27. A client has been treated for a deep vein thrombus and today presents to the clinic with
petechiae. Laboratory results show a platelet count of 42,000/mm3. The nurse reviews the clients
medication list to determine if the client is taking which drug?
a. Enoxaparin (Lovenox)
b. Salicylates (aspirin)
c. Unfractionated heparin
d. Warfarin (Coumadin)
28. The nurse assesses a clients oral cavity and makes the discovery shown in the photo below:
What action by the nurse is most appropriate?
a. Encourage the client to have genetic testing.
b. Instruct the client on high-fiber foods.
c. Place the client in protective precautions.
d. Teach the client about cobalamin therapy.
MULTIPLE RESPONSE
1. A nurse working with clients with sickle cell disease (SCD) teaches about self-management to
prevent exacerbations and sickle cell crises. What factors should clients be taught to avoid? (Select
all that apply.)
a. Dehydration
b. Exercise
c. Extreme stress
d. High altitudes
e. Pregnancy
EXAM 1 211 – Test Bank Questions
2. A student studying leukemias learns the risk factors for developing this disorder. Which risk
factors does this include? (Select all that apply.)
a. Chemical exposure
b. Genetically modified foods
c. Ionizing radiation exposure
d. Vaccinations
e. Viral infections
3. A client has Hodgkins lymphoma, Ann Arbor stage Ib. For what manifestations should the nurse
assess the client? (Select all that apply.)
a. Headaches
b. Night sweats
c. Persistent fever
d. Urinary frequency
e. Weight loss
4. A client has a platelet count of 25,000/mm3. What actions does the nurse delegate to the
unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Assist with oral hygiene using a firm toothbrush.
b. Give the client an enema if he or she is constipated.
c. Help the client choose soft foods from the menu.
d. Shave the male client with an electric razor.
e. Use a lift sheet when needed to re-position the client.
5. A student nurse is helping a registered nurse with a blood transfusion. Which actions by the
student are most appropriate? (Select all that apply.)
a. Hanging the blood product using normal saline and a filtered tubing set
b. Taking a full set of vital signs prior to starting the blood transfusion
c. Telling the client someone will remain at the bedside for the first 5 minutes
d. Using gloves to start the clients IV if needed and to handle the blood product
e. Verifying the clients identity, and checking blood compatibility and expiration time
6. A student nurse is learning about blood transfusion compatibilities. What information does this
include? (Select all that apply.)
a. Donor blood type A can donate to recipient blood type AB.
b. Donor blood type B can donate to recipient blood type O.
c. Donor blood type AB can donate to anyone.
d. Donor blood type O can donate to anyone.
e. Donor blood type A can donate to recipient blood type B.
7. A client with chronic anemia has had many blood transfusions. What medications does the nurse
anticipate teaching the client about adding to the regimen? (Select all that apply.)
a. Azacitidine (Vidaza)
b. Darbepoetin alfa (Aranesp)
c. Decitabine (Dacogen)
d. Epoetin alfa (Epogen)
e. Methylprednisolone (Solu-Medrol)
EXAM 1 211 – Test Bank Questions
8. A nurse is preparing to administer a blood transfusion to an older adult. Understanding agerelated changes, what alterations in the usual protocol are necessary for the nurse to implement?
(Select all that apply.)
a. Assess vital signs more often.
b. Hold other IV fluids running.
c. Premedicate to prevent reactions.
d. Transfuse smaller bags of blood.
e. Transfuse each unit over 8 hours.
9. A client has heparin-induced thrombocytopenia (HIT). The student nurse asks how this is
treated. About what drugs does the nurse instructor teach? (Select all that apply.)
a. Argatroban (Argatroban)
b. Bivalirudin (Angiomax)
c. Clopidogrel (Plavix)
d. Lepirudin (Refludan)
e. Methylprednisolone (Solu-Medrol)
10. A client has received a bone marrow transplant and is waiting for engraftment. What actions by
the nurse are most appropriate? (Select all that apply.)
a. Not allowing any visitors until engraftment
b. Limiting the protein in the clients diet
c. Placing the client in protective precautions
d. Teaching visitors appropriate hand hygiene
e. Telling visitors not to bring live flowers or plants